Change chart in the Nursing Home Enquiry

Aug 6th, 2022
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How to change chart in the Nursing Home Enquiry

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i remember when i was a new grad i was a complete mess i would just scramble to write things down and when someone asked me to give report it was kind of like i was either running in a circle or i would never get to the point [Music] hey friends its trish im back with another video and today im going to be showing you guys how i organize my nurse brain so if youre not familiar with what a nurse brain is its basically where all the nurses write their notes down for the shift including their assessment times any important tasks that they have to any meds that they need to give so if you see nurses walking around like i lost my brain have you seen my brain i lost my brain its because all their notes are on there for the shift so sometimes when youre new it can help for you to see someone elses brain so ive actually included for you guys down below a copy of my brain i have two different versions one is a short and concise version and then the other one is a two-page version that

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Action can be taken only if changes are noticed and reported, the earlier the better. Changes that are not reported can lead to serious outcomes, including medical complications, transfer to a hospital, or even death.
However, abnormal vital signs or docHub changes in client status pertaining to breathing, circulation, cognition, pain, or falls should be immediately reported to the nurse for rapid assessment and intervention to ensure client health and safety.
Examples are bleeding, pain, or injury. Restraints (ordered by a doctor) require reporting to the nurse. Other circumstances that require immediate reporting: skin changes, falls, patient complaints, difficult behavior, suicidal or dangerous behavior, and discovery of alcohol or drugs.
Whenever a long-term care resident develops an acute illness, such as a urinary tract infection, pneumonia, or a fall in blood sugar, for example, the individual is said to be undergoing a change in condition(COC). Any sudden illness that causes COC can increase the risk of falling.
Because the cardiovascular system is vital for health, any symptoms related to chest pain, shortness of breath, or lack of oxygenation should be immediately reported to the nurse.
Be accurate, objective, and complete. Include data relating to all aspects of patient care and the nursing process. Refrain from documenting inappropriate, subjective opinions, conclusions, or derogatory statements about patients, colleagues, or other members of the patient care team.
A change in a residents condition may mean that he or she is at risk. Action can be taken only if changes are noticed and reported, the earlier the better. Changes that are not reported can lead to serious outcomes, including medical complications, transfer to a hospital, or even death.

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